Mortality, Morbidity, Growth and Development of Babies Weighing 501–1000 Grams and 1001–1500 Grams at Birth

ABSTRACT. During the five-year period, January 1980 to December 1984, 149 babies of extremely low birthweight (ELBVV; 501–1000 g) and 296 of very low birthweight (VLBVV; 1001–1500 g) were admitted to King's College Hospital, Neonatal Intensive Care Unit. The survival rates were 51.7 % and 82.8 % respectively. There were more peri- and postnatal problems in the ELBVV babies than the VLBW babies and these differences were highly significant. All surviving babies born between January 1980 and December 1982 were followed up until aged two. The ELBW children had a higher incidence of neuro-developmental sequelae than those of VLBW especially when both major and minor problems were considered. Their developmental quotients were lower at one and two years. Significantly more ELBW children were of short stature and low weight (<3rd centile). By two years of age the differences between ELBW and VLBW children in stature and mean DQ had lessened.     

Predictive factors for survival for out‐born infants born between 23 and 24 weeks of gestation in the post‐surfactant era: Fourteen years’ experience in a single neonatal care unit, 1987–2000

Background: The purpose of the present paper was to identify the predictive factors for survival for out‐born infants born between 23 and 24 weeks of gestation. Methods: Ninety‐two infants born between 23 and 24 weeks’ gestation who were admitted to a level III neonatal intensive care unit from 1987 to 2000, were retrospectively studied. Survival was defined as discharge from the neonatal intensive care unit. Logistic regression was done to determine which clinical factors were most predictive of survival. The independent variables that were entered into the models were determined by preliminary univariate analysis. Results: Ninety‐two infants were enrolled in the present study, 49 of whom survived in the surfactant era. The four variables that were found to be most predictive for survival on logistic regression were systolic blood pressure at 6 h (odds ratio [OR], 1.3; 95% confidence interval [CI]: 1.11–1.44 1 mmHg), ventilatory index < 0.047 (OR, 4.8; 95%CI: 1.07–21.65), initial hemoglobin value (OR, 1.6; 95%CI: 1.09–2.34/1 g/dL), and base excess at 6 h (OR, 2.1; 95%CI: 1.08–1.84/5 mEq/L). Conclusions: A total of 53.2% of infants delivered between 23 and 24 weeks of gestation survived at discharge after introduction of surfactant replacement therapy. Early cardiopulmonary adaptation and initial hemoglobin value are key factors for survival in infants born at 23–24 weeks of gestation.     

The Swedish national prospective study on extremely low birthweight (ELBW) infants. Incidence, mortality, morbidity and survival in relation to level of care

In a 2-year (1990-92) prospective national investigation, comprising all stillborn and live-born ELBW infants with a birthweight of ≤1000 g born at 23 completed weeks of gestation or more, we examined the incidence, neonatal mortality, major morbidity and infant survival in relation to level of care and place of residence. A total of 633 ELBW infants were live-born, i.e. 0.26% of all live-born infants, and 298 were stillborn. The average neonatal mortality was 37% and 91% at 23 weeks, 70% at 24 weeks, and 40% at 25 weeks of gestation. Of neonatal survivors, 8% had intraventricular haemorrhage grade 3,10% retinopathy of prematurity of stage ≥3, 2% necrotizing enterocolitis, and 28% were oxygen-dependent at a time corresponding to 36 weeks of gestation. In all, 77% were treated with mechanical ventilation, whereas 19% survived without, almost all of them being CPAP treated. Infant mortality among infants born at level III (tertiary centres) was 30%, at level Ha (with full perinatal service) 46% and at level IIb (with basic neonatal service) 55 %. Only 1 % was born at hospital level I. Regarding the relation to place of residence, the mortality rates among infants residing in the areas served by levels III, IIa and lib hospitals were 36%, 45% and 41%, respectively. The referral system thus functioned well, but can be improved, and increased perinatal referral, at borderline perinatal viability, might provide a better quality of care and a better chance of survival.     

Early surfactant in spontaneously breathing with nCPAP in ELBW infants – a single centre four year experience

Objective: To evaluate whether the experience with a method to administer surfactant during spontaneous breathing with nasal continuous positive airway pressure (nCPAP) as primary respiratory support in infants with respiratory distress syndrome (RDS) influences the frequency of its use and affects the outcome of patients.
Methods: All inborn extremely low birthweight (ELBW) infants treated after introduction of the method were retrospectively studied (n = 196). The entire observational period was divided into four periods (periods 1–4) and compared with a control period (period 0) (n = 51). Primary respiratory support, demographics, prenatal risks and outcomes were compared.
Results: There were no changes in demographics or prenatal risks over time. The choice of nCPAP as initial airway management significantly increased from 69% to 91% and for nCPAP with surfactant from 75% to 86%. The rate of nCPAP failure decreased from 46% to 25%. Survival increased significantly between periods 0 and 1 from 76% to 90% and survival without bronchopulmonary dysplasia (BPD) rose from 65% to 80%. No changes in nonpulmonary outcomes were observed.
Conclusion: The success of nCPAP increased with increasing use of nCPAP with surfactant. Simultaneously, mortality decreased without deterioration of other outcomes indicating that the use of surfactant in spontaneous breathing with nCPAP could be beneficial.     

Changing survival and impairment rates at 18–24 months in outborn very low-birth-weight infants: 1984–1987 versus 1980–1983

Outcomes at 18–24 months corrected age of very low-birth-weight infants admitted to our Neonatal Intensive Care Unit in 1984–1987 (period 2) were compared with the outcomes of infants admitted in 1980–1983 (period 1) (total 1357 infants). In the 500–750–g birth-weight subgroup, the survival rate increased from 32 to 54% ( p = 0.002). Rates of moderate and severe impairment at 18–24 months (neurosensory deficit, or Bayley corrected mental developmental index ≤68) in this subgroup decreased from 41 to 15% ( p = 0.005), and in those without severe impairment, mean mental Bayley scores in periods 1 and 2 were 84 ± 18 and 90±16, respectively (p = 0.20). Analysis after exclusion of small-for-gestational-age infants gave similar results. In the small-for-gestational-age infants of birth weight 500–750 g, the survival rate increased but the impairment rate was unchanged between periods. It is concluded that outcomes improved in 1984–1987 compared with 1980–1983 only for infants with birth weight of 500–750 g.     

Changing survival and impairment rates at 18–24 months in outborn very low-birth-weight infants: 1984–1987 versus 1980–1983

Outcomes at 18–24 months corrected age of very low-birth-weight infants admitted to our Neonatal Intensive Care Unit in 1984–1987 (period 2) were compared with the outcomes of infants admitted in 1980–1983 (period 1) (total 1357 infants). In the 500–750–g birth-weight subgroup, the survival rate increased from 32 to 54% ( p = 0.002). Rates of moderate and severe impairment at 18–24 months (neurosensory deficit, or Bayley corrected mental developmental index <68) in this subgroup decreased from 41 to 15% ( p = 0.005), and in those without severe impairment, mean mental Bayley scores in periods 1 and 2 were 84 ± 18 and 90 ± 16, respectively (p = 0.20). Analysis after exclusion of small-for-gestational-age infants gave similar results. In the small-for-gestational-age infants of birth weight 500–750 g, the survival rate increased but the impairment rate was unchanged between periods. It is concluded that outcomes improved in 1984–1987 compared with 1980–1983 only for infants with birth weight of 500–750 g.     

Unstudied infants: outcomes of moderately premature infants in the neonatal intensive care unit

BACKGROUND: Newborns of 30-34 weeks gestation comprise 3.9% of all live births in the United States and 32% of all premature infants. They have been studied much less than very low birthweight infants. OBJECTIVE: To measure in-hospital outcomes and readmission within three months of discharge of moderately premature infants. DESIGN: Prospective cohort study including retrospective chart review and telephone interviews after discharge. SETTING: Ten birth hospitals in California and Massachusetts. PATIENTS: Surviving moderately premature infants born between October 2001 and February 2003. MAIN OUTCOME MEASURES: (a) Occurrence of assisted ventilation during the hospital stay after birth; (b) adverse in-hospital outcomes-for example, necrotising enterocolitis; (c) readmission within three months of discharge. RESULTS: With the use of prospective cluster sampling, 850 eligible infants and their families were identified, randomly selected, and enrolled. A total of 677 families completed a telephone interview three months after hospital discharge. During the birth stay, these babies experienced substantial morbidity: 45.7% experienced assisted ventilation, and 3.2% still required supplemental oxygen at 36 weeks. Readmission within three months occurred in 11.2% of the cohort and was higher among male infants and those with chronic lung disease. CONCLUSIONS: Moderately premature infants experience significant morbidity, as evidenced by high rates of assisted ventilation, use of oxygen at 36 weeks, and readmission. Such morbidity deserves more research.     

Economic outcome for intensive care of infants of birthweight 500–999 g born in Victoria in the post surfactant era

Objective: To determine the incremental cost of improving the outcome for extremely low birthweight (ELBW, birthweight 500–999 g) infants born in Victoria after the introduction of exogenous surfactant (the post surfactant era). Methodology: This was a geographically determined cohort study of ELBW children in Victoria, Australia of consecutive livebirths born in three distinct eras: (i) 1979–80 (n= 351); (ii) 1985–87 (n= 560); and (iii) 1991–92 (n= 429). Exogenous surfactant was first used in Victoria in March, 1991. The consumption of nursery resources per livebirth, and the survival and sensorineural disability rates at 2 years of age for each era were investigated. Utilities were assigned as follows: 0 for dead, 0.4 for severe disability, 0.6 for moderate disability, 0.8 for mild disability, and 1 for no disability. Utilities were multiplied for more than one disability. Dollar costs were assumed to be $1470 ($A 1992) per day of assisted ventilation, and one dose of exogenous surfactant was assumed to be equivalent to one third of a day of assisted ventilation. Cost-effectiveness (additional costs per additional survivor or life-year gained) and cost-utility (additional costs per additional quality-adjusted survivor or life-year gained) ratios were calculated for the pre-surfactant era (1985–87 vs 1979–80), and for the post surfactant era (1991–92 vs 1985–87). Results: Considering only the costs incurred during the primary hospitalization, cost-effectiveness and cost-utility ratios were lower (i.e. economically better) in the post surfactant era than in the pre-surfactant era (pre-surfactant vs post surfactant; S7040 vs$4040 per life year gained; $6700 vs$5360 per quality-adjusted life year gained). Both ratios fell with increasing birthweight. In contrast with the pre-surfactant era, cost-utility ratios were less favourable than cost-effectiveness ratios in the post surfactant era. With costs for long-term care of severely disabled children added, both cost ratios were higher in the post surfactant era. Conclusion: The incremental cost during the primary hospitalization of improving the outcome for ELBW infants has fallen in the post surfactant era.     

Outcome to 8 years of infants <1000 g birthweight: Relationship with neonatal ventilator and oxygen therapy

The study involved a cohort of 59 consecutive survivors with birthweights less than 1000 g, born between 1977 and 1980, to 8 years of age. The aim of the report was to determine if those survivors who had received more oxygen and ventilator therapy differed in their outcome compared with those who had received less oxygen and ventilation. Children were graded into four groups, characterized by decreasing durations of oxygen and ventilation. Children who had received less oxygen and ventilation were more likely to be below the third percentile for weight at 2, 5 and 8 years but the trends were significant only at 2 and 5 years (P = 0.006, P = 0.013 and P = 0.19 respectively). The rate of cerebral palsy was 8% at 8 years; the only children with severe or moderate disabilities from their cerebral palsy were in the lowest oxygen and ventilation group (n = 4, P less than 0.02). The frequency of hospital re-admission and the duration of re-hospitalization did not vary significantly between the four groups at any age. The rates of recurrent wheezing episodes or asthma did not vary significantly between the groups. Although the cohort as a whole had some impairment of lung function compared with healthy full-term controls, there was no significant difference between the four groups. Contrary to expectations, our findings suggest lower rates of poor growth and adverse neurological outcomes with increasing durations of oxygen and ventilation in the newborn period.     

A national study of risk factors associated with mortality in very low birthweight infants in the Malaysian neonatal intensive care units

To determine the risk factors associated with mortality in very low birthweight (VLBW) infants admitted to the neonatal intensive care units (NIUC) in Malaysia.

Method:

A prospective observational study of outcome of all VLBW infants born between 1 January 1993 and 30 June 1993 and admitted to the NICU.

Results:

Data of 868 VLBW neonates from 18 centres in Malaysia were collected. Their mean birthweight was 1223 g (95% confidence intervals: 1208–1238 g). Thirty-seven point four per cent (325/868) of these infants died before discharge. After exclusion of all infants with congenital anomalies ( n =66, and nine of them also had incomplete records) and incomplete records ( n =82), stepwise logistic regression analysis of the remaining 720 infants showed that the risk factors that were significantly associated with increased mortality before discharge were: delivery in district hospitals, Chinese race, lower birthweight, lower gestation age, persistent pulmonary hypertension of the newborn, pulmonary airleak, necrotizing enterocolitis of stage 2 or 3, confirmed sepsis, hypotension, hypothermia, acute renal failure, intermittent positive pressure ventilation, and umbilical arterial catheterization. Factors that were significantly associated with lower risk of mortality were: use of antenatal steroid, oxygen therapy, surfactant therapy and blood transfusion.

Conclusion:

The mortality of VLBW infants admitted to the Malaysian NICU was high and was also associated with a number of preventable risk factors.     

新生儿重症监护病房极低出生体质量儿头围增长速度对1 岁龄神经发育结局的影响

目的以新生儿重症监护病房内极低出生体质量儿的不同头围增长速度预测纠正满1岁时的神经运动发育结局。方法前瞻性收集2016年6月至2017年12月入住新生儿重症监护病房的极低出生体质量(出生体质量1 500 g)早产儿,动态监测住院期间头围增长速度,按不同头围增长速度百分位数分为缓慢增长组(增长速度P_(10))、中度增长组(增长速度P_(10)～P_(90))和快速增长组(增长速度P_(90))。持续随访至纠正满1岁,运用贝利婴幼儿发育量表评估神经运动发育,分为发育迟缓(≤69分)、临界(70～79分)和正常(≥80分)组,比较各组体格发育及并发症情况。结果 131例研究对象,平均胎龄(30.29±2.06)周,平均出生体质量(1 280±184)g,住院期间头围增长平均速度为(0.49±0.19)cm/周。缓慢增长组、中度增长组和快速增长组的头围增长速度分别为(0.12±0.05)cm/周、(0.49±0.13)cm/周和(0.81±0.03)cm/周;中度增长组和快速增长组的纠正1岁龄的智力发育指数(MDI)和运动发育指数(PDI)均高于缓慢增长组,差异有统计学意义(P0.05)。MDI临界组和正常组的头围增长速度均大于发育迟缓组,PDI正常组的头围增长速度大于发育迟缓组,差异均有统计学意义(P0.05)。结论极低出生体质量儿住院期间头围增长速度与纠正满1岁时的神经运动发育结局具有相关性。     

Breastfeeding promotion in neonatal intensive care unit: impact of a new program toward a BFHI for high-risk infants

AIM: The study evaluates a breastfeeding promotion program in an Italian neonatal intensive care unit (NICU) over a period of time. METHODS: Clinical data of the newborns admitted in the NICU of the Bambino Gesu' Children's Hospital in Rome in 2002 were gathered (78; program implemented) and were compared to similar data collected in 1998 (76; prior to the program) and in 2000 (50; program activated). Breastfeeding management during hospitalization and infant feeding after discharge were examined through maternal interviews. RESULTS: The general features of the newborns and their parents were comparable. In 2002, the rate of exclusively breastfeeding (at breast and/or expressed mother's milk) the first day at home was 51.2% and 64% in 2000 versus 21.2% in 1998 (p < 0.001). In the subset of newborns <1500 g (VLBWI), the exclusively breastfeeding rate improvement was even more striking after program activation: 55.5% (2002) and 64.3% (2000) versus 4.5% (1998; p < 0.001). The impact of several recognized risk factors (medical condition of the infants, length of hospitalization, distance from maternal residence, type of delivery) on exclusively breastfeeding rate was significantly reduced after the program was implemented, except for higher maternal age. CONCLUSIONS: The implementation of a breastfeeding promotion program in NICU has a markedly positive effect on exclusive breastfeeding rate early after discharge. Further studies are necessary in order to adapt the Baby-Friendly Hospital Initiative (BFHI) approach to the NICU setting, taking into account the characteristics of such high-risk infants.     

Acute peritoneal dialysis in neonatal intensive care unit: An 8-year experience of a referral hospital

Background

The aim of present study was to evaluate the indications, complications and outcomes of acute peritoneal dialysis (APD) in neonates at a referral university hospital during the previous 8 years.